madman
Super Moderator
ABSTRACT
Background
Gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32–65%, depending on the age and the criteria used for definition. GM of infancy and puberty are common, benign conditions resolving spontaneously in the majority of cases. GM of adulthood is more prevalent among the elderly and proper investigation may reveal an underlying pathology in 45–50% of cases.
Objectives
The aim was to provide clinical practice guidelines for the evaluation and management of GM.
Materials and methods
A literature search of articles in English for the term ‘gynecomastia’ was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.
Results
A set of five statements and fifteen clinical recommendations was formulated.
Conclusions
The purpose of GM assessment should be the detection of underlying pathological conditions, reversible causes (administration/abuse of aggravating substances), and discrimination from other breast lumps, particularly breast cancer. Assessment should comprise a thorough medical history and physical examination of the breast and genitalia (including testicular ultrasound). A set of laboratory investigations may integrate the evaluation: testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetal protein (AFP), liver and renal function tests. Breast imaging may be used whenever the clinical examination is equivocal. In suspicious lesions, core needle biopsy should be sought directly instead. Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with GM. T treatment should be offered to men with proven T deficiency. The use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and non-aromatizable androgens is not justified in general. Surgical treatment is the therapy of choice for patients with long-lasting GM.
SUMMARY OF STATEMENTS (S) AND RECOMMENDATIONS (R)
S1. Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in males.
S2. GM of infancy is a common condition that usually resolves spontaneously, typically within the first year of life.
S3. GM of puberty is a common condition, affecting approximately 50% of mid-pubertal boys; in more than 90% of cases, it resolves spontaneously within 24 months.
S4. The prevalence of GM in adulthood increases with increasing age; proper investigation may reveal an underlying pathology in approximately 45–50% of the cases.
S5. Male breast cancer is rare; GM should not be considered a premalignant condition.
INTRODUCTION—DEFINITION
Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in men. The term is derived from the Greek words ‘gyneka’ (woman) and ‘mastos’ (breast). GM can be unilateral or bilateral, most commonly the latter (Nuttall, 1979; Mieritz et al., 2017). GM has to be distinguished from pseudogynecomastia (i.e., lipomastia), which is characterized by excess fat deposition without glandular proliferation. GM is a common condition with a prevalence that varies widely between 32 and 65%, depending on the age of the subjects studied and the criteria used for GM definition (Braunstein, 2007). GM shows three discrete peaks throughout a man’s lifespan: the first peak is observed during infancy, the second during puberty, and the third in middle-aged and elderly men (Nachtigall, 1965; Knorr & Bidlingmaier, 1975; Nuttall, 1979). The purpose of the assessment of GM should be the detection of underlying pathological conditions and the discrimination from other breast lumps that mimic GM, particularly breast cancer.
CONCLUSIONS
GM is a common condition associated with benign hormonal processes of maturation of the male adolescent in the majority of cases. On the other hand, GM of the elderly is more often associated with underlying pathological conditions. The assessment of GM should aim at the detection of such conditions or the administration/abuse of aggravating substances as well as the exclusion of the very rare male breast cancer. The cornerstones of assessment are thorough medical history and physical examination including the breast and genitalia (supported by testicular ultrasound). Laboratory investigations may reveal underlying systematic disorders, whereas the role of breast imaging is still debated: Core needle biopsy should be sought in any clinically suspicious breast lesion. Watchful waiting and reassurance are reasonable options after underlying pathology, or the administration/abuse of substances associated with GM has been excluded or treated. The use of medical regimens, including SERMS, AIs, or DHT, still lacks substantial evidence to recommend their generalized use, while surgical treatment remains the therapy of choice for patients with long-lasting GM.
Table 1 Causes of gynecomastia
Cause
Physiological and idiopathic
• Neonatal/infancy
• Pubertal
• Middle or advanced age
Pathological
• Medications
• Primary testosterone deficiency (particularly Klinefelter syndrome)
• Secondary testosterone deficiency
• Hyperthyroidism
• Neoplasms
• Testicular: originating from germ (secreting forms), Leydig or Sertoli cells
• Adrenal: androgen- or estrogen-secreting tumors
• Ectopic production of hCG
• Hepatic causes, malnutrition
• Renal causes
• Rare causes
• Enzymatic defects of testosterone production
• Androgen insensitivity syndromes
• True hermaphroditism
• Excessive extra-glandular aromatase activity
• Environmental polluting substances
Background
Gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32–65%, depending on the age and the criteria used for definition. GM of infancy and puberty are common, benign conditions resolving spontaneously in the majority of cases. GM of adulthood is more prevalent among the elderly and proper investigation may reveal an underlying pathology in 45–50% of cases.
Objectives
The aim was to provide clinical practice guidelines for the evaluation and management of GM.
Materials and methods
A literature search of articles in English for the term ‘gynecomastia’ was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.
Results
A set of five statements and fifteen clinical recommendations was formulated.
Conclusions
The purpose of GM assessment should be the detection of underlying pathological conditions, reversible causes (administration/abuse of aggravating substances), and discrimination from other breast lumps, particularly breast cancer. Assessment should comprise a thorough medical history and physical examination of the breast and genitalia (including testicular ultrasound). A set of laboratory investigations may integrate the evaluation: testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetal protein (AFP), liver and renal function tests. Breast imaging may be used whenever the clinical examination is equivocal. In suspicious lesions, core needle biopsy should be sought directly instead. Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with GM. T treatment should be offered to men with proven T deficiency. The use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and non-aromatizable androgens is not justified in general. Surgical treatment is the therapy of choice for patients with long-lasting GM.
SUMMARY OF STATEMENTS (S) AND RECOMMENDATIONS (R)
S1. Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in males.
S2. GM of infancy is a common condition that usually resolves spontaneously, typically within the first year of life.
S3. GM of puberty is a common condition, affecting approximately 50% of mid-pubertal boys; in more than 90% of cases, it resolves spontaneously within 24 months.
S4. The prevalence of GM in adulthood increases with increasing age; proper investigation may reveal an underlying pathology in approximately 45–50% of the cases.
S5. Male breast cancer is rare; GM should not be considered a premalignant condition.
INTRODUCTION—DEFINITION
Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in men. The term is derived from the Greek words ‘gyneka’ (woman) and ‘mastos’ (breast). GM can be unilateral or bilateral, most commonly the latter (Nuttall, 1979; Mieritz et al., 2017). GM has to be distinguished from pseudogynecomastia (i.e., lipomastia), which is characterized by excess fat deposition without glandular proliferation. GM is a common condition with a prevalence that varies widely between 32 and 65%, depending on the age of the subjects studied and the criteria used for GM definition (Braunstein, 2007). GM shows three discrete peaks throughout a man’s lifespan: the first peak is observed during infancy, the second during puberty, and the third in middle-aged and elderly men (Nachtigall, 1965; Knorr & Bidlingmaier, 1975; Nuttall, 1979). The purpose of the assessment of GM should be the detection of underlying pathological conditions and the discrimination from other breast lumps that mimic GM, particularly breast cancer.
CONCLUSIONS
GM is a common condition associated with benign hormonal processes of maturation of the male adolescent in the majority of cases. On the other hand, GM of the elderly is more often associated with underlying pathological conditions. The assessment of GM should aim at the detection of such conditions or the administration/abuse of aggravating substances as well as the exclusion of the very rare male breast cancer. The cornerstones of assessment are thorough medical history and physical examination including the breast and genitalia (supported by testicular ultrasound). Laboratory investigations may reveal underlying systematic disorders, whereas the role of breast imaging is still debated: Core needle biopsy should be sought in any clinically suspicious breast lesion. Watchful waiting and reassurance are reasonable options after underlying pathology, or the administration/abuse of substances associated with GM has been excluded or treated. The use of medical regimens, including SERMS, AIs, or DHT, still lacks substantial evidence to recommend their generalized use, while surgical treatment remains the therapy of choice for patients with long-lasting GM.
Table 1 Causes of gynecomastia
Cause
Physiological and idiopathic
• Neonatal/infancy
• Pubertal
• Middle or advanced age
Pathological
• Medications
• Primary testosterone deficiency (particularly Klinefelter syndrome)
• Secondary testosterone deficiency
• Hyperthyroidism
• Neoplasms
• Testicular: originating from germ (secreting forms), Leydig or Sertoli cells
• Adrenal: androgen- or estrogen-secreting tumors
• Ectopic production of hCG
• Hepatic causes, malnutrition
• Renal causes
• Rare causes
• Enzymatic defects of testosterone production
• Androgen insensitivity syndromes
• True hermaphroditism
• Excessive extra-glandular aromatase activity
• Environmental polluting substances
